§ 31-3875.06. Review personnel qualifications.

(a) (1) A utilization review entity shall ensure that an adverse determination is made by a physician who:

(A) Possesses a current and valid non-restricted license to practice medicine in the District, Maryland, or Virginia; and

(B) Is of the same or similar specialty as a physician who typically manages the medical condition or disease or provides the health care service involved in the request; provided, that a physician making an adverse determination for pediatric care shall have a pediatric specialty.

(2) The reviewing physician shall:

(A) Be under the clinical direction of one of the utilization review entity's medical directors licensed in the District who is responsible for providing health care services to enrollees in the District; and

(B) Not receive any financial incentive based on the number of adverse determinations made; except, that the utilization review entity may establish medically appropriate performance standards.

(b) (1) A utilization entity shall ensure that all appeals are reviewed by a physician who:

(A) Possesses a current and valid non-restricted license to practice medicine in the District, Maryland, or Virginia;

(B) Is of the same or similar specialty as a physician who typically manages the medical condition or disease or provides the health care service involved in the request; provided, that the physician reviewing an appeal for pediatric care shall have a pediatric specialty and practiced that specialty for at least 5 years; and

(C) Is knowledgeable of, and have experience providing, the health care service on appeal.

(2) A physician reviewing an appeal shall not:

(A) Receive any financial incentive based on the number of adverse determinations made or upheld on appeal; provided, that the utilization review entity may establish medically appropriate performance standards;

(B) Have been directly involved in making the adverse determination; and

(C) Be subordinate of the physician who made the adverse determination.